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Why Don't Some Doctors or Healthcare Facilities Accept My Insurance?

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Updated March 24, 2012

Question: Why Don't Some Doctors or Healthcare Facilities Accept My Insurance?
When it's time to find a doctor, whether we need primary care or a specialist, our choices are limited by doctors who are willing to work with our chosen health insurance. How does that work? Why do doctors accept some payers and not others? How does this affect a patient's care?
Answer:

Among all the frequently asked questions about the mysteries of healthcare, the question about why doctors or facilities do, or don't, accept some forms of insurance as payment for their services is most answerable by "follow the money."

In order to understand the answer, we need to understand how health insurance works:

Each year, doctors and healthcare facilities like testing labs, hospitals, pharmacies and others, negotiate pricing with health insurers and payers. In its simplest form, it goes like this:

Doctor: When a patient with diabetes visits my office, I charge $100 for the visit, and $75 for the blood work.

Payer: That's too much money. We'll pay you $55 for the visit and $35 for the blood work.

Doctor: I can't pay my staff or keep my lights turned on for that paltry amount! How about $65 for the visit and $45 for the blood work?

Payer: Deal.

That negotiation takes place for every possible service your doctor performs, with every insurance company, each year.

Some insurance companies refuse to pay some doctors the amount those doctors believe they are entitled to be paid. When that happens, the doctor will stop accepting that form of insurance as reimbursement.

Then, of course, once the doctor no longer accepts that insurance company's reimbursement schedule, then she no longer accepts patients who use that payer's insurance.

We can't pass judgment on whether a doctor should, or should not, accept the amount of money a payer is willing to pay. For one reason, we have a free enterprise system of healthcare payment. Each doctor in private practice, or each hospital or other lab or facility has a right to charge what it wants to charge, and which payers it wishes to work with.

Here's another way to think about it. Suppose you went to work and did your job well. When it came time to get your paycheck, your employer told you he had decided your services weren't really worth what you expected to be paid, so he was going to begin paying you less. Take it or leave it. That's the position doctors are put in by payers each year.

We also have to recognize that when payers reimburse at the higher amounts a doctor wants to be paid, it costs us patients more in the forms of premiums, co-pays, higher deductibles and sometimes taxes, too.

Be aware, too, that doctors may change plans, or insurers and payers may add or drop doctors from year to year. Whenever you make an appointment, or change insurance plans, it's always good to double check whether you will be able to see the doctors you usually see.

What can you do to be sure your insurance will pay for the doctors you want to see?

  • If the doctors you want to see are more important to you than what it costs to visit them, then contact their offices and ask which insurance payers they will accept reimbursement from. Then choose from among the plans they accept. It's possible they accept only some plans from an insurer, and not all, so be sure to ask them to list the specific plans they accept.
  • If you are limited to only some insurers or some plans, then check with those plans to see which doctors are on their lists of providers. This information is often found on the payer's websites, or you can call their customer service phone numbers to ask.

What can you do if you want to see a specific doctor and he doesn't accept any of the insurance plans you are eligible for?

  • Pay cash for the visit. Be sure to make this arrangement ahead of time, though. Not all doctors will accept cash payments.
  • Find a doctor who runs a concierge or boutique practice. These doctors don't accept insurance in most cases. Since you pay them cash anyway, insurance doesn't have to be a consideration.
  • See an out-of-network doctor even though you will have to pay more to see him or her. Just be careful to track the billing and be sure you are not balance billed beyond what should take place.

Learn why "follow the money" is the answer to more doctors' appointments mysteries:

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